What would you have done???

[babynurselsa]

Left wrok with yet another big ole hunk of my butt missing......

Last night when I recieved report for m a new orientee, I was told that my baby had an rder for 2 doses of Lasix. She had given the first. The order was to give it IM. I grinched about the route. I can't remember ever having had to give Lasix IM. Well when it came time for the dose I noted that she had recorded a dose of 6mg. The normal dose is 1mg/kg. I double checked the Dr. order, it did in fact read 6mg, IM. This baby weighs 1975g. I double checked the Neofax. which read: 1mg/kg, slow IVP, IM,PO. may increase to 2 mg/kg IV. Up to 6 mg/Kg PO. I called our Moonlighter told him what my order read. His reaction was the same as mine. (What in the world!?!?!?) He told me to give 6mg but to give it PO. I carried out the order as clarified by my Moonlighter.

The next morning I weent and told the Neo what I had done, that I questioned the order becausee it was a dose that was higher than I could ever remeber having given. He immediately went into a tirade about how he wrote the order and that was exactly what he wanted done. I was out of line for questioning his order. He was sick and tired of "people" going behind him and changing his orders.

I tried to reiterate that our accepted Pharm. resource did not state that the order was approprtiate. That I had called the physician to clarify the order when I had a question, and that was why I was asking him about it that am to get clarification straight from him. Essentially his response was that no matter what the Neofax had said I shoulld have just given it because that is the way HE wrote it, so obvioulsy that is what he wanted done.

I just wonder what anyone else waould have done.

[RNKitty]

I always feel that one of the reasons nurses sign off the order is as a double check. Doctors are human and can make mistakes. This way, at least two people have seen the order and signed their name to it. My signature means I saw it and I verified that it was an appropriate order for that patient. I always document any double checks with the docs. CYA every time! Good for you for looking out for this little tyke. You could be my baby's nurse anytime!

[mommyrn]

Hi everyone. I am an RN student, and this discussion makes me so nervous. We have spent a lot of time on legal issues this semester, and all we as students keep hearing is how nasty many doctors get when you question them. My philosophy is that I WILL question any order that doesn't seem right to me because it's my butt on the line, but I hate the fact that we, as nurses, are put in such a position where we have to be made to feel as if we are doing something wrong for thinking in the best interest of the patient. I hate this whole "superiority complex" that many physicians have, and even some nurses in the clinical areas that we as students encounter during our rotations. We are all in this to help the patients....or so I thought......It just makes me nervous that so much of this goes on. I pitty the poor naiive nurse who is unable to stand up to someone of authority out of fear of being reamed out, only to lose his or her license because of an error that could have been prevented. Any suggestions on how to best approach this situation for us students? Thanks!

[Jenny P]

I'm not sure what a Neofax is, but I do know that in my hospital if the pharmacy sees an order that is out of line, they call and question the nurse about the order.

When I get an unusual order, I definitely question the doc about it, and will write him up if he acts like a jerk! I will also ask someone to witness my call on a second line if the doc is a notorious A-hole. And document it in the chart that the order was clarified with the doc with a witness (name the witness-ie: M.Jones, RN); and also that you spoke to pharmacy about the order; as that may be the only way to CYA. I don't ever want to lose my license because some doc thinks he's ommnipotent. After those 6 nurses (I think it was in Colorado about 2-3 years ago?) gave the wrong doses of chemo drugs and lost their licenses while following the doctors' orders (I believe the pt. died); I'm very careful about odd orders.

Babynurselsa, that doc didn't take a chunk out of your butt; he just showed you what a real A-hole is. You did the right thing; keep protecting those little babies from mistakes.

[Teshiee]

It is a medicine book that NICU nurses uses for finding out proper dosages to give our little tykes. You will find them in Peds sometimes but mainly in the NICU units.

[KARRN3]

YOU DID THE ABSOLUTE RIGHT THING. AS NURSES, OUR JOB IS TO ADVOCATE FOR AND TO PROTECT OUR PATIENTS. IF A DOCTOR WROTE AN ORDER SO FAR OUT OF THE NORM I'D TELL HIM TO COME IN AND GIVE IT HIMSELF. WE NOT ONLY HAVE THE RIGHT, BUT AN OBLIGATION TO ADDRESS QUESTIONABLE ORDERS. THE DAYS OF "DO IT BECAUSE I'M THE DOCTOR AND I SAID SO WENT OUT WITH GLASS SYRINGES AND CHECKING NEEDLES FOR BURRS."NURSES ARE EDUCATED AND SHOULD NEVER BE AFRAID OR INTIMIDATED INTO THINKING ANYTHING LESS.

[NRSKarenRN, BSN, RN]

Stock response: 'You can spend a little bit of time now....or a lot of time later in court if something goes wrong" in my most sugar sweet voice I can find. " An ounce of Prevention worth a pound or cure".

Learned that leason while an LPN the hard way in 1980 after a patient coded and died 3 days later in CCU. I wrote explicitly in chart that I wanted to notify Attending re deteriorating ABG's despite multiple O2 changes ordered by 1st year intern. RN Nursing Supervisor wouldn't allow operator to put call thru at 3:30 AM. (The Interns need to learn how to handle these patients, her response.) Multiple notations re attempts to contact in house staff....finally called ER Doc 15 min before pt actually coded.

That documentation saved my butt but STILL chewed out by unit Medical Director that he should have been called to question orders--------informed him no access to telephone number- his number promptly placed in narcotic box for any Staff to call him at home. NEVER trusted that doctor again...even after he became Chief Resident 2 years latter.

Learned from the incident MY license would have been on the line and need to go up chain of command for ALL problems till satisfaction received or all medical/nursing administration notified.

Kudus to you for putting your PATIENT FIRST.

[NicuGal, MSN, RN]

We use the Neofax and a peds guidebook. We just went to unit dose (hate it) so we didn't have a pharmacist to catch the errors, just me, myself and I. But alot of newer people think it is okay if an attending orders it. For out of order orders we have to have a fellow and an attending sign it. If it is really bizarre we tell them to give it themselves.

[Jolie, BSN]

You absolutely did the right thing! I agree with the posters who recommended having the physician administer the med himself. I also want to emphasize the importance of having a witness when you question an order, and keeping a written log of such incidents. I once had a neonatologist remove an order from a baby's chart. It happened to be at the top of a new order sheet, so he was able to do so easily without having to "reconstruct" other orders and signatures. He and I both knew what he had done, but I couldn't prove it. In my case it did not involve anything serious that could harm the baby. It was more of a pi**ing match between him and me, but I learned then and there never to trust the snake. I informed him that I would no longer accept verbal or phone orders from him, and that I would personally see that 2 RN's signed off on his orders from that day forward so that he could never pull that stunt again.

[P_RN, ADN, RN]

I too have had the slithery serpents try to pull order sheets (with stupid/illegal/WRONG orders) from a chart. Fortunately for the good guys the order sheets were the carbonless 2 part ones.

The back copy was always immediately sent to the pharmacy no matter what...even things like change diet etc.

I've had them try to sneak another order in the next morning.....

I've had a PA write an order that was cosigned by a doc's partner...and then the attending come in and try to obliterate the med that was ordered and GIVEN!

Pharmacy back copy saved my tukkus both times.

All my life I've lived by certain axioms...

"If it ain't broke, don't fix it." And

"When in doubt, DON'T."

[shay]

You absolutely did the right thing. Teeny baby + K depleting big time diuretic overdose = sick/critical/dead teeny baby.

First and foremost, do no harm.

You are a good nurse. Stick by your guns.

Neofax was my bible when I worked NICU. Protect those little ones. You go, girl.

[babynurselsa, RN]

Thanks so muc4h for the feedback.

I did indeed make a a c0opy of the written order written by Himself, made a copy of the childs BMP from the next morning, and a copy of the page from the Neofax. Thank God somehow her K+ was Ok the Next morning but her Na was 128 and her Chloride was 93. When he complained to me that I had not called him personally about the clarification I told him that if that was what he wanted in the future I would be more than happy to call him at home in the middle of the night rather than the Moonlighters he has staffed us with. Well at least he hasn't repeated the dose on this poor child just to continue to try and convince us tha he really did mean to write that order that way.